Emergency medicine

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Emergency Medicine

Schematic diagram of a normal sinus rhythm for a human heart as seen on an ECG.

Emergency medicine is a medical specialty involving care for adult and pediatric patients with acute illnesses or injuries that require immediate medical attention. While not usually providing long-term or continuing care, emergency physicians, who usually have a D.O. or M.D. degree, diagnose a variety of illnesses and undertake acute interventions to resuscitate and stabilize patients. Emergency medicine physicians generally practice in hospitalemergency departments, pre-hospital settings via emergency medical services, other locations where initial medical treatment of illness takes place, and recently the intensive-care unit. Just as clinicians operate by immediacy rules under large emergency systems, emergency practitioners aim to diagnose emergent conditions and stabilize the patient for definitive care.

Emergency Medicine is a medical specialty—a field of practice based on the knowledge and skills required for the prevention, diagnosis and management of acute and urgent aspects of illness and injury affecting patients of all age groups with a full spectrum of undifferentiated physical and behavioral disorders. It further encompasses an understanding of the development of pre-hospital and in-hospital emergency medical systems and the skills necessary for this development.[1]

Emergency medicine encompasses a large amount of general medicine and surgery including the surgical sub-specialties. Emergency physicians are tasked with seeing a large number of patients, treating their illnesses and arranging for disposition—either admitting them to the hospital or releasing them after treatment as necessary. The emergency physician requires a broad field of knowledge and advanced procedural skills often including surgical procedures, trauma resuscitation, advanced cardiac life support and advanced airway management. Emergency Physicians must have the skills of many specialists—the ability to resuscitate a patient (critical care medicine), manage a difficult airway (anesthesia), suture a complex laceration (plastic surgery), reduce (set) a fractured bone or dislocated joint (orthopedic surgery), treat a heart attack (cardiology), work-up a pregnant patient with vaginal bleeding (Obstetrics and Gynecology), stop a bad nosebleed (ENT), place a chest tube (cardiothoracic surgery), and to conduct and interpret x-rays and ultrasounds (radiology).

Emergency medicine is distinct from urgent care, which refers to immediate healthcare for non-emergency medical issues. In fact, urgent care has its roots in emergency medicine when in the 1970s, physicians extended hours of practice to focus on non-emergency issues.[2]

During the French Revolution, after seeing the speed with which the carriages of the French flying artillery maneuvered across the battlefields, French military surgeon Dominique Jean Larrey applied the idea of ambulances, or "flying carriages", for rapid transport of wounded soldiers to a central place where medical care was more accessible and effective. Larrey manned ambulances with trained crews of drivers, corpsmen and litter-bearers and had them bring the wounded to centralized field hospitals, effectively creating a forerunner of the modern MASH units. Dominique Jean Larrey is sometimes called the father of Emergency Medicine for his strategies during the French wars.

Emergency Medicine (EM) as a medical specialty is relatively young. Prior to the 1960s and 1970s, in general hospital emergency departments were staffed by physicians on staff at the hospital on a rotating basis, among them general surgeons, internists, psychiatrists, and dermatologists. Physicians in training (interns and residents), foreign medical graduates and sometimes nurses also staffed the Emergency Department (ED). EM was born as a specialty in order to fill the time commitment required by physicians on staff to work in the increasingly chaotic emergency departments (EDs) of the time. During this period, groups of physicians began to emerge who had left their respective practices in order to devote their work completely to the ED. The first of such groups was headed by Dr. James DeWitt Mills who, along with four associate physicians; Dr. Chalmers A. Loughridge, Dr. William Weaver, Dr. John McDade, and Dr. Steven Bednar at Alexandria Hospital, Virginia, established 24/7 year-round emergency care, which became known as the "Alexandria Plan". It was not until the establishment of American College of Emergency Physicians (ACEP), the recognition of Emergency Medicine training programs by the AMA and the AOA, and in 1979 a historical vote by the American Board of Medical Specialties that EM became a recognized medical specialty.[3] The first Emergency Medicine residency program in the world was begun in 1970 at the University of Cincinnati[4] and the first Department of Emergency Medicine at a U.S. medical school was founded in 1971 at the University of Southern California.[5]

Emergency medicine traces its development as a specialty in UK to 1952 when Mr Maurice Ellis was appointed as the first consultant in Emergency Medicine in the UK at Leeds General Infirmary. In 1967, the Casualty Surgeons Association was established with Maurice Ellis as its first President.[6] The name of the Association was changed twice, in 1990, to the British Association for Accident and Emergency Medicine, and later on in 2004, to British Association for Emergency Medicine (BAEM). In 1993, Intercollegiate Faculty of Accident and Emergency Medicine (FAEM) was formed at the Royal College of Surgeons of England, London. In 2005, the BAEM and the FAEM were merged to form College of Emergency Medicine.[7] The College of Emergency Medicine is the single authoritative body for Emergency Medicine in the UK. It conducts its fellowship and membership exams, publishes guidelines and standards for the practise of Emergency Medicine, and has its own journal, called the Emergency Medicine Journal (EMJ).[8]

In Argentina, the SAE (Sociedad Argentina de Emergencias) is the main organization of Emergency Medicine. There are a lot of residency programs. Also is possible to reach the certification with a two-year postgraduate university course after a few years of ED background.

In Australia and New Zealand, specialist training in Emergency Medicine is overseen by the Australasian College for Emergency Medicine (ACEM). The ACEM also offers formal qualifications and continuing professional education for non-specialists who have Emergency Medicine responsibilities.

In India, many private hospitals and institutes have been providing Emergency Medicine training for doctors, nurses & paramedics since 1994. The certification programs varied from 6 months to 3 years. Emergency Medicine was recognized as a separate specialty by Medical Council of India (MCI) only from July 2009. After this, many medical colleges are about to start postgraduate training, i.e., MD in Emergency Medicine. It will be at least a few years until the specialty gets streamlined in India.[citation needed] Colleges such as Sri Ramachandra Medical College, Chennai, Vinayaka Missions University, Salem and Christian Medical College, Vellore were among the first to establish and empower Emergency Medicine and a structured Post Graduate program. 3 year Emergency medicine residency is also provided by Apollo hospitals at various sites (Hyderabad, Chennai, Delhi, and Bangalore) making the candidates eligible to appear for MCEM examinations.

The National Board of Examinations has announced that DNB emergency medicine would be started from the next academic session at various accredited hospitals/colleges in India.

Emergency medicine is an upcoming branch in India, which is growing at a rapid pace.

In Saudi Arabia, Certification of Emergency Medicine is done by taking the 4-year program Saudi Board of Emergency Medicine (SBEM), which is accredited by Saudi Council for Health Specialties (SCFHS). It requires passing the two-part exam: first part and final part (written and oral) to obtain the SBEM certificate, which is equivalent to Doctorate Degree. http://saudiemergencymedicine.com/welcome/index.php

Saudi Society of Emergency Medicine SASEM is an organization that encompasses all emergency doctors in Saudi Arabia.

In Canada, there are two routes to certification in emergency medicine. The vast majority of full-time practicing emergency physicians in Canada are certified via one of these routes. Most busy urban, sub-urban, and larger rural hospitals are staffed primarily by full-time, certified career emergency physicians. Smaller rural and community hospitals may still be staffed by family physicians who work in the emergency department on a part-time rotating basis. Basic experience in emergency medicine is a core component of family medicine training in Canada. The general trend in Canadian emergency departments over the last decade has been the gradual replacement of part-time, non-certified physicians (mostly family physicians) by full-time certified emergency physicians. This trend was first noted in larger academic centers but has gradually evolved to include most busy emergency departments.

The two routes to emergency medicine certification can be summarized as follows:

CCFP(EM) emergency physicians outnumber FRCP(EM) physicians by a ratio of about 3 to 1, and they tend to work primarily as clinicians with a smaller focus on academic activities such as teaching and research. FRCP(EM) Emergency Medicine Board specialists tend to congregate in academic centers and tend to have more academically oriented careers, which emphasize administration, research, critical care, disaster medicine, and teaching. They also tend to sub-specialize in toxicology, critical care, pediatrics emergency medicine, and sports medicine. Furthermore, the length of the FRCP(EM) residency allows more time for formal training in these areas.

As a consequence of the above, most Canadian medical students wishing to pursue an academic emergency medicine career and/or work primarily in a major academic center choose the FRCP route of certification. On the other hand, those wishing to function primarily as clinical emergency physicians choose the CCFP route of certification.

Although many physicians in the emergency medicine community in Canada feel that a unified training process would be beneficial to the current 2-stream schism, this has yet to happen for a variety of complex reasons.[State reasons with citation]

There are only two academic societies in EM in China, Chinese Association of EM (CAEM) and Chinese College of Emergency Physicians (CCEP, equivalent to ACEP in US). CAEM was established in 1986, under the management of the China Medical Society (CMS). However, CCEP was organized by the Ministry of Public Health in 2009. Their primary missions and tasks are not yet clearly defined. As a matter of fact, there are some overlaps in terms of organization administrators and academic activities.

There are three universities (Universiti Sains Malaysia [USM], Universiti Kebangsaan Malaysia [UKM], & Universiti Malaya [UM]) that offer Masters in Emergency Medicine. These post-graduate trainings consists of 4 years of various clinical trainings in the field relevant to Emergency Medicine (EM) practices. The certifications consists of clinical posting evaluations, year 1 and year 4 examinations and research projects (dissertation) with satisfactory completion is mandatory. The 1st batch of Emergency Physician (EP) trained locally had graduated in 2002. The EM field in Malaysia has developed tremendously over the past 10 years. The College of Emergency Physician (CEP) was formed under the Academy of Medicine Malaysia (AMM) recently that strengthen further this fraternity.

In the United Kingdom and Ireland, the College of Emergency Medicine sets the examinations that trainees in Emergency Medicine take in order to become consultants (fully trained Emergency Physicians). Physicians that have passed the fellowship examination of the college of Emergency Medicine are awarded the post nominals 'FCEM'.

In the United States, there are many member organizations for emergency clinicians:

The American Academy of Emergency Medicine (AAEM) restricts its membership to board certified specialists in Emergency Medicine, and as of 2009 has over 6000 members. It promotes the independence of Emergency Physicians and seeks to limit the interference of corporations and other outside groups in the doctor-patient relationship.

The American College of Emergency Physicians (ACEP) is the oldest and largest professional organization. Originally founded in 1968, it now has over 25,000 members, although some became members before board certification in Emergency Medicine was required.[9][10]

The Emergency Department Practice Management Association (EDPMA) is a trade association that offers membership to Emergency Medicine Physician groups and their practice business partners, including billing companies and emergency department supporting organizations like EMR firms, consultants, and scribe companies. Founded in 1997, EDPMA's members make it their business to deliver quality care in the emergency department.

The Emergency Medicine Residents' Association (EMRA) is an organization that offers membership to Emergency Medicine Physicians in training (residents and medical students) and graduates of ACGME and AOA Emergency Medicine residency training programs. Originally founded in 1972, EMRA represents the interests of Emergency Medicine physicians-in-training. As of 2014 EMRA has nearly 12,000 members.

In the United States and Canada, there are five ways to become Board Certified in Emergency Medicine:

The Board of Certification in Emergency Medicine (BCEM) is the fifth designation - outside of the ABEM, AOBEM, RCPSC, or CFPC-EMCE exams. The BCEM is the only organization in the United States that will grant board certification in Emergency Medicine to a physician who has not completed an Emergency Medicine residency but have experience in another field. (http://www.abms.org/who_we_help/physicians/specialties.aspx). BCEM allows physicians who were not initially residency-trained in Emergency Medicine, but that have completed a residency in other fields (internists, family practitioners, pediatricians, general surgeons, and anesthesiologists), to become board-certified in Emergency Medicine. BCEM requires five years of full-time Emergency Medicine experience, preparation of case reports for review by the board, and passing both written and oral examinations before allowing a candidate to become board-certified in Emergency Medicine. Recertification is required every 8 years. BCEM is under the control of the American Association of Physician Specialists (AAPS) - an organization that allows both M.D.s and D.O.s to become members.

The specialist medical college responsible for Emergency Medicine in Australia and New Zealand is the Australasian College for Emergency Medicine (ACEM).[16] The training program is nominally seven years in duration, after which the trainee is awarded a Fellowship of ACEM, conditional upon passing all necessary assessments.[17]

Basic Training (24 months): Pre-vocational hospital rotation experience, which usually consists of the PGY1 internship year and PGY2 year as a junior medical officer.[18]

Provisional Training (12 months): 6 months of Emergency Medicine training, plus 6 months of elective experience. Trainees must pass the ACEM Primary Examination before the end of this period, which tests basic and clinical science knowledge of trainees.[19]

Advanced Training (48 months): 30 months of Emergency Medicine training, 6 months of intensive care and/or anaesthesia training, and 18 months of elective training relevant to Emergency Medicine. Trainees must pass the ACEM Fellowship Examinations in order to qualify as an Emergency Medicine specialist at the end of this period.[20]

For medical doctors not (and not wishing to be) specialists in Emergency Medicine but have a significant interest or workload in emergency departments, the ACEM provides non-specialist certificates and diplomas.[22] The EM Certificate requires minimum three years of postgraduate experience as a medical doctor, completion of minimum six months supervised training in Emergency Medicine, and pass marks in formal examinations.[23] The EM Diploma requires attainment of an EM Certificate (or equivalent training and experience), completion of a further 12 months of supervised training in Emergency Medicine and 6 months supervised training in clinical anaesthesia or intensive care, and pass marks in examinations.[24]

In Canada, there are a few different ways to become certified as an emergency physician. For all methods, one has to first complete a medical degree. The next most common step is to complete two years of family medicine residency offered by the College of Family Physicians of Canada (CFPC), followed by a third year of residency in the emergency medicine enhanced skills program.[25] There is also a five-year residency program offered by the Royal College of Physicians and Surgeons of Canada that may be completed instead of the aforementioned one. The CFPC also allows those having worked a minimum of 4 years at a minimum of 400 hours per year in emergency medicine to challenge the examination of special competence in emergency medicine and thus become specialized.[25]

The current post-graduate Emergency Medicine training process is highly complex in China. The first EM post-graduate training took place in 1984 at the Peking Union Medical College Hospital. Because specialty certification in EM has not been established, formal training is not required to practice Emergency Medicine in China. For those physicians that do choose to obtain training in EM, several options are available. Graduates from medical school can apply directly to hospitals for staff physician-in-training positions, which eventually lead to a staff position at that same hospital. In addition, physicians from smaller hospitals can go to those larger academic centers for a 6 to 12-month post-graduate re-education. While these physicians may undergo the same training as the staff physicians, they will return to their own hospital once their training is completed. Finally, physicians having completed previous post-graduate training may choose to apply for fellowship positions for further training in Emergency Medicine.

About one decade ago, Emergency Medicine residency training was centralized at the municipal levels, following the guidelines issued by The Ministry of Public Health. Residency programs in all hospitals are called residency training bases, which have to be approved by local health governments. These bases are hospital-based, but the residents are selected and managed by the municipal associations of medical education. These associations are also the authoritative body of setting up their residents' training curriculum. All medical school graduates wanting to practice medicine have to go through 5 years of residency training at designated training bases, first 3 years of general rotation followed by 2 more years of specialty-centered training.

Emergency Medicine is a popular field for medical school graduates to enter. Both Doctors of Medicine (M.D) and Doctors of Osteopathic Medicine (D.O) can be fully trained and licensed as an Emergency Physician. In addition to the didactic exposure, much of an Emergency Medicine residency involves rotating through emergency departments, intensive care units, pediatric and obstetric units, and other specialties. By the end of their training, Emergency Physicians are expected to handle a vast field of medical, surgical, and psychiatric emergencies, and are considered specialists in the stabilization and treatment of emergent conditions.

Emergency medical trainees enter specialty training after five years of medical school and two years of foundation training.

During the two-year core training programme (Acute Care Common Stem), doctors complete training in anaesthesia, acute medicine, intensive care, and Emergency Medicine.[27] In the third year, the trainee learns about Emergency Medicine (paediatric focus) and musculo-skeletal Emergency Medicine. They must also pass the Membership of the College of Emergency Medicine (MCEM) examination. Trainees will then go onto Higher Training, lasting a further 3 years. Before the end of higher training, the final examination—the Fellowship of the College of Emergency Medicine (FCEM) must be passed. Upon completion of training the doctor will be eligible for entry on the GMC Specialist Register and allowed to apply for a post as a Consultant in Emergency Medicine.

Emergency Medicine training in the UK is emerging. Historically, emergency specialists were drawn from anaesthesia, medicine, and surgery. Many established EM consultants were surgically trained; some hold the Fellowship of Royal College of Surgeons of Edinburgh in Accident and Emergency—FRCSEd(A&E). Some of these consultants will be referred to as 'Mister', whilst others choose either not to change from 'Doctor' or to change back to 'Doctor' after passing the FCEM exam. Others used the MRCP or the FRCA as their primary examination (now replaced by MCEM). Trainees in Emergency Medicine may dual accredit in Intensive-Care Medicine or seek sub-specialisation in Paediatric Emergency Medicine.[28]

The only way to become a certified Emergency Medicine Physician is via attending Medical Board Examination (TUS) to become a resident. After TUS, candidates are allocated to different residencies according to their score and choice.

Emergency Medicine residency lasts for 4 years in Turkey. During the programme doctors complete 13 months of rotation on different specialties, including anesthesia, orthopedics, pulmonary medicine, internal medicine, pediatrics, general surgery, radiology, neurosurgery, neurology, and cardiology. Last year, they design and manage a clinical or animal research, and write their dissertations. At the end of their residency they attend two different exams three months apart: Dissertation Exam, Emergency Medicine Specialty Exam. Both exams are oral, and doctor is expected to answer all questions asked by the Exam Board. Exam Board consists of 5 members: 2-3 from Emergency Medicine, others from Internal Medicine, Surgery or Anesthesia faculty members. After the exam, doctor starts to hold the title of Emergency Medicine Specialist. However, all the doctors should attend a 2-year Obligatory Service in Turkey to be qualified to have their diploma. After this period, EM specialist can choose to work in private or governmental ED's.

Emergency Medicine training in Pakistan lasts for 5 years. The candidate enters the program by clearing part 1 of FCPS (fellow of college of physicians and surgeons of Pakistan) and passing the entry test of one of the institutions offering Emergency Medicine residency in Pakistan. The initial 2 years involve trainees to be sent to various sub-specialties including both medicine and surgery. Major rotations include, Internal Medicine, ICU, Anesthesia and Pediatrics. The residents enrolled in the program rotate for 3 months each of first two years. They work in the emergency Department for about six months. After the two years they appear in the exams called Intermediate Module (IMM). In last three years trainee residents spend most of their time in emergency room as senior residents. Full-time faculty supervises the residents. The duration can vary from 60–80 hours per week depending upon the rotation. There is an extensive curriculum that is covered over 5 years. Certain certificate courses include ACLS, PALS, ATLS, and research and dissertations are required for successful completion of the training. At the end of 5 years, candidates become eligible for sitting for FCPS part II exam. After completion of requirements and passing the exam, the physician is called Emergency Medicine specialist and they can use FCPS with their names.

First residency program in Iran started in 2002 at Iran University of Medical Sciences (which merged with Tehran University of Medical Sciences later). There are now three-year standard residency programs running in Tehran, Tabriz, Mashhad, Isfahan, and some other universities. All these programs work under supervision of Emergency Medicine specialty board committee. There are now more than 200 (and increasing) board-certified Emergency Physicians in Iran.[15]

The employment arrangement of Emergency Physician practices are either private (a democratic group of EPs staff an ED under contract), institutional (EPs with an independent contractor relationship with the hospital), corporate (EPs with an independent contractor relationship with a third-party staffing company that services multiple emergency departments), or governmental (employed by the US armed forces, the US public health service, the Veteran's Administration or other government agency).

Most Emergency Physicians staff hospital emergency departments in shifts, a job structure necessitated by the 24/7 nature of the emergency department. In the United States, Emergency Medicine practitioners are expected to be competent in treating, diagnosing and managing a wide array of illnesses and conditions, both chronic and acute. Overall, more than half of Emergency Physicians report high levels of career satisfaction. Although career satisfaction has remained high among Emergency Physicians, concern about burnout is substantial.[29]

In the United Kingdom, all Consultants in Emergency Medicine work in the NHS. There is little scope for private emergency practice.

In Australia and New Zealand, Emergency Medicine specialists are almost always salaried employees of government health departments and work in public hospitals, with pockets of employment in private or non-government aeromedical rescue or transport services, as well as some private hospitals with emergency departments. The emergency departments themselves are usually headed by a cadre of salaried Emergency Medicine specialists (Fellows of ACEM), backed by non-specialist medical officers, and visiting general practitioners (i.e. "family physicians" in US parlance). Rural emergency departments are usually headed by general practitioners, sometimes with non-specialist qualifications in Emergency Medicine.

In Turkey, EM specialist may choose to work in private (corporate hospitals), governmental (all the hospitals under Ministry of Health) or institutional (University Hospitals) EDs. However most of the EPs work in governmental or university hospitals.

A U.S. government report found there were 119 million emergency department visits in 2006, an increase of 36% from 1996. During this same ten-year period of increased usage, the number of emergency departments decreased, from 4,019 to 3,833 and the rate of emergency department visits per 100 people in the U.S. rose from 34.2 to 40.5.[30]